Medication Contamination/Misadministration
Unexplained presence of an allergic medication in a patient's system, raising concerns about contamination or misadministration.
245 items
9 sources
1 inquiry
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
85match
Dominic Philip
The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or poor stock control.
Matched on
terms: contamination, medication
PFD report
65match
Lily Girton
Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, hindering timely care access. The care plan was not updated despite escalating hospital concerns, leaving the patient without necessary support.
Matched on
terms: medication
PFD report
65match
Aaron Atkinson
There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 months after initiating antipsychotic medication.
Matched on
terms: medication
PFD report
61match
Alan Peck
Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred with the patient, depriving him of essential drugs during transport.
Matched on
terms: medication
PFD report
61match
Marjorie Ellery
Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment was not informed consent.
Matched on
terms: medication
PFD report
61match
Annette Charlton
Pharmaceutical manufacturers are producing medications in almost identical packaging, which significantly increases the risk of dispensing errors and poses a serious threat to patient safety.
Matched on
terms: medication
PFD report
61match
Jerome Peat
A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive significantly more medication than intended and resulting in an overdose.
Matched on
terms: medication
PFD report
61match
Susan Young
Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, creating a risk of further overdose.
Matched on
terms: medication
PFD report
57match
Sneh Chaudhry
Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic medication.
Matched on
terms: medication
PFD report
57match
Marie Millward-Winter
Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.
Matched on
terms: medication
PFD report
57match
Ian Hall
Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from receiving wrong prescriptions.
Matched on
terms: medication
PFD report
57match
John Skinner
A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication risk when numbers are expressed orally in clinical settings.
Matched on
terms: medication
PFD report
57match
David Martin
A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the oversight.
Matched on
terms: medication
PFD report
57match
Sidra Aliabase
Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and a significant delay in recognizing and treating subsequent hypocalcaemia.
Matched on
terms: medication
IMB recommendation
57match
Drake Hall (2024)
The Board is concerned about the ongoing problems regarding medication management. This has three components: o The process for administration of medications needs a complete and radical overhaul. o A means of controlling prescription medication needs to be found to reduce the risks associated with trading medications. o The design of the dispensary does not facilitate the effective...
Matched on
terms: medication
LGO / SPSO decision
56match
PSOW-202101243 - Cardiff and Vale University Health Board
Mr X complained that the Health Board had failed to prescribe him a newly approved medication called Fampridine, a drug used to improve walking ability in patients with multiple sclerosis. Mr X said this resulted in him paying for private prescriptions when he should have received the treatment from the NHS. The Ombudsman found that the Health Board...
Matched on
terms: medication
PFD report
53match
Frederick Davidson
Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication breakdown between junior doctor and consultant, lack of pneumothorax recognition, premature authorisation of feeding, and delays in X-ray reporting were highlighted.
Matched on
classifier match
PHSO casework decision
53match
P-001392 - Royal Free London NHS Foundation Trust
Mrs E complains the Trust gave her late husband, Mr E, a stronger dose of chemotherapy medication than was required on 28 August 2019. She says the dose should have been reduced as he was experiencing an infection.
Matched on
terms: medication
IMB recommendation
52match
Berwyn (2020)
Inpatient units/Medication Policy
Matched on
terms: medication
IMB recommendation
52match
North West and Midlands STHF (2023)
For the fifth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding...
Matched on
terms: medication
LGO / SPSO decision
52match
PSOW-202005941 - Cwm Taf Morgannwg University Health Board
Mrs A complained that a GP Practice in the area of Cwm Taf Morgannwg University Health Board failed to arrange a timely referral to secondary care for her late mother, Mrs G, between 20 January and 18 March 2020 in relation to increasingly painful symptoms in her lower left leg. Mrs A was later admitted to hospital on...
Matched on
terms: medication
PFD report
49match
Jessica Bond
Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine rupture and associated complications.
Matched on
classifier match
PFD report
49match
Lydia Corah
An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, and adversely affecting the intended patient.
Matched on
classifier match
PFD report
49match
Gabriele Kreichgauer
The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource led to ineffective treatment. The resource also lacked a clinician feedback mechanism for inaccuracies.
Matched on
classifier match
PFD report
49match
KennethDaly
Unclear advice from consultants regarding co-prescribing multiple opioids and a lack of tailored written guidance for patients on the risks of combined opioid use were identified.
Matched on
classifier match
PFD report
49match
Doris Clark
A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units between services creates a significant safety concern.
Matched on
classifier match
PFD report
49match
Colin Beaumont
A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.
Matched on
classifier match
PFD report
49match
Michele Duckworth
The patient was incorrectly prescribed Tazocin, an antibiotic against trust guidelines due to prior ESBL colonization, an error that was repeatedly missed during medical reviews.
Matched on
classifier match
IMB recommendation
48match
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That the administration of detainees’ personal prescribed medication in airport HRs be resolved forthwith.
Matched on
terms: medication
IMB recommendation
48match
Bedford (2021)
There are issues around the dispensing of medication that need resolving. Some prisoners are not receiving their medication, while others may be selling it on, as there has been inadequate supervision at the pharmacy.
Matched on
terms: medication
IMB recommendation
48match
Hollesley Bay (2023)
A review of the arrangements for dispensing medication is requested. The current regime is slow and cumbersome, which causes frustration for prisoners and friction with healthcare staff.
Matched on
terms: medication
IMB recommendation
48match
Forest Bank (2024)
The Board has received complaints about medication treatment dispensing times being missed frequently, which has an impact on prisoners’ health. What action will the prison take to improve this outcome?
Matched on
terms: medication
PHSO casework decision
48match
P-004653 - United Lincolnshire Teaching Hospitals NHS Trust
Mrs B complains about the care and treatment her father, Mr C, received by the Trust between April and May 2023. Specifically, she says the Trust did not give her father the correct medication, unsafely discharged him and delayed its complaint response because it lost his medical records.
Matched on
terms: medication
PHSO casework decision
48match
P-001072 - Manchester University NHS Foundation Trust
Ms A complains on behalf of her deceased brother, Mr B, who had a cardiac arrest at Manchester University NHS Foundation Trust, however the family were not made aware of this. Ms A also says that a doctor wrongly inserted an NG tube and instructed a nurse to inject 40mls of fluid and medication into his lung. Mr...
Matched on
terms: medication
PHSO casework decision
48match
P-001648 - University Hospitals of North Midlands NHS Trust
Mrs N complains the Trust did not apply her mother's fentanyl (a strong painkiller) patch properly. She says its record keeping was poor and she complains it skipped giving other medication. She says her mother was left without pain relief and then given morphine which was harmful to her.
Matched on
terms: medication
PHSO casework decision
48match
P-001620 - University Hospitals of North Midlands NHS Trust
Mrs A complains about her mother's, Mrs B's, end of life care saying the Trust did not give the right medication and antibiotics were delayed.
Matched on
terms: medication
PHSO casework decision
48match
P-002693 - Imperial College Healthcare NHS Trust
Mr H complains that the London Trust inappropriately administered alteplase to his father although he was already taking blood-thinning medications. Mr H also complains that the Imperial Trust damaged an artery in his father’s brain when undertaking a procedure to remove the blood clot.
Matched on
terms: medication
PHSO casework decision
48match
P-003448 - East Sussex Healthcare NHS Trust
Miss B and her mother complain East Sussex Healthcare NHS Trust administered the wrong medication to Mr B just before he died, denied it gave him it and did not record this properly in the medication chart. They also complain it did not contact them soon enough when Mr B deteriorated and did not try contacting the second...
Matched on
terms: medication
PHSO casework decision
48match
P-004160 - Mid and South Essex NHS Foundation Trust
Mrs G complains during her husband’s admission in August and September 2023, the Trust administered a medication it should not have, failing to monitor its impact of his blood sugar, failing to provide appropriate nutrition considering his raised blood sugar, poor oral intake, weight loss and drowsiness. Mrs G also complains the Trust delayed her husband’s urgent bypass...
Matched on
terms: medication
IMB recommendation
48match
North and Midlands Short Term Holding Facilities (2022)
For the fourth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding...
Matched on
terms: medication
IMB recommendation
48match
Wandsworth (2023)
Non delivery of medications has been a major concern to the Board this year. What is being done to ensure that this improves?
Matched on
terms: medication
IMB recommendation
48match
Styal (2023)
The Board continues to have concerns around the safe and timely administration and dispensing of medication. What will be done to address the inadequate accommodation for the pharmacy service including the way in which medicines, including methadone, are transported?
Matched on
terms: medication
IMB recommendation
48match
Wandsworth (2024)
Non delivery of medications has been a major concern to the Board this year. What is being done to ensure that this improves?
Matched on
terms: medication
PHSO casework decision
48match
P-001385 - Lewisham and Greenwich NHS Trust
Ms E complains that Lewisham and Greenwich NHS Trust gave her incorrect treatment, documented incorrect information in her records relating to medication, and lost her ECG reports from 24 December 2018. She also says the Trust have failed to respond to her further letter of concerns.
Matched on
terms: medication
PHSO casework decision
48match
P-001559 - West Hertfordshire Hospitals NHS Trust
Mrs A and Mrs Y complain the Trust wrongly stopped Mr Y’s antiplatelet medication and did not act on their concerns Mr Y was having a stroke. They also complain during the same admission the Trust delayed diagnosis of Mr Y’s peritoneal cancer.
Matched on
terms: medication
PHSO casework decision
48match
P-003706 - Norfolk and Norwich University Hospitals NHS Foundation Trust
Mr L complains the Trust left him without eye drops for his cystinosis for eight weeks and failed to tell him when to stop taking his doxazosin medication whilst he was an inpatient.
Matched on
terms: medication
LGO / SPSO decision
47match
PSOW-202504068 - Swansea Bay University Health Board
Miss A complained that the Health Board prescribed and administered the incorrect dose of epilepsy medication to her 3-year old daughter when she attended the Emergency Department. Miss A said that despite having evidence of the prescribed medication, the Health Board said that there was no record of a prescription being given to her daughter. Miss A said...
Matched on
terms: medication
PFD report
45match
Norma Sheppard
The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically regarding the provision of sub-cutaneous fluids, which presented difficulties in finding a suitable placement.
Matched on
classifier match
PFD report
45match
Michael Anthony
The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for which was undetermined, and that the drug is usually not prescribed in diabetics due to the risk of severe reaction.
Matched on
classifier match
PFD report
45match
Elsie Mallalieu
Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.
Matched on
classifier match